In April 2016, three for-profit companies took over management of Iowa’s Medicaid program. Then-Gov. Terry Branstad says the program is saving the state money, but the companies say they are losing money. Critics worry about a loss of services.

Health advocates are warning that dentists across Iowa may stop accepting Medicaid patients because of the state's move to shift management of the dental system to for-profit companies.

A clause in the new contracts signed with those for-profit management companies says dentists who accept Medicaid can't discriminate against patients based on their eligibility to enroll in the program.

Some dentists have cried foul, saying they believe the contracts would prohibit them from deciding how many Medicaid patients they take.

Instead, they've threatened to stop accepting any Medicaid patients, which could lead to drastic shortages of care.

“I can tell you I’ve talked with many dentists individually, and they’ve just been wringing their hands about what to do about this,” said Larry Carl, executive director of the Iowa Dental Association

Dentists are reluctant to take too many Medicaid patients because the program pays 70 percent less than non-Medicaid customers.

If dentists can't limit their number of Medicaid patients, they will not be able to keep their businesses financially afloat, advocates said.

“I’m willing to do my part. But you can only do so much,” said Ryan Stuntz, a dentist from Farley who has stopped accepting adult Medicaid patients.

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The management switch, which affects dental services for 158,433 Iowans, means the private companies, rather than state employees, now manage their dental care.

It also means enrollees are required to complete a health assessment and partake in an annual dental exam to avoid monthly premiums.

Iowa will continue to manage the program for people who are 19 years old or younger.

Segments of Iowa’s $60 million annual dental care program for poor and elderly Iowans have been managed for years by two private companies — MCNA Insurance Co. and Delta Dental of Iowa.

The Iowa Department of Human Services said the number of dentists who accept Medicaid patients in the past year has increased from 223 to 354 for MCNA and from 788 to 818 for Delta Dental.

But health advocates warn that those numbers may be premature, as dentists such as Stuntz determine whether they can afford to continue to provide service to poor and elderly Iowans on the program.

“You might ask, ‘How can a dentist stay in business when being paid 30 cents on the dollar? They can’t,” Carl said. “Up to this point, they’ve been able to manage the number” of Medicaid patients.

This month’s switch was made to ease the administrative burden — not as a cost-saving measure, said Amy McCoy, a spokeswoman for the Iowa Department of Human Services.

McCoy said the non-discrimination provision in the contracts is required by federal law but does not mandate that dentists accept every Medicaid patient.

She referred to the private companies questions about reconciling the language of the contract with her statement that dentists can reject Medicaid patients.

Delta Dental declined to discuss the matter, and MCNA did not respond to questions.

Carl and Stuntz remain concerned, particularly about the apparent contradiction between the contracts and McCoy's statements.

Stuntz said an attorney who reviewed the contracts for him said he could face federal sanctions, including fines, if he were to sign the contract and reject some Medicaid patients.

The private management of the dental plan follows Iowa’s effort last year that privatized management of most of the other portion of Medicaid. Then-Gov. Terry Branstad said the move would save Iowa more than $100 million annually.

Those plans are the subject of an ongoing federal lawsuit alleging the private companies have illegally withheld health services to disabled Iowans.

Primary Health Care and Broadlawns Medical Center — two organizations that specialize in providing dental and other health services to low-income Iowans — said they are reserving judgment as they continue to monitor the new privately managed dental programs.

Those organizations, unlike private dentists, are nonprofit and sometimes are the recipients of grants that help defray the costs of services.

Examples include a recent $120,000 anonymous donation to Broadlawns that allowed the dental clinic to purchase 3-D scanning equipment and a $371,500 grant from Delta Dental. Dozens of dental students also temporarily practice without pay each year at Broadlawns as part of their learning curriculum.

Last year the clinic provided more than 9,400 patient visits. That number is expected to grow, partly because of the possibility that fewer private-practice dentists will accept Medicaid patients, said Hayley Harvey, a dentist and section chief at the center.

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Dr. Hayley Harvey in the Dental Clinic at the new medical plaza at Broadlawns Medical Center, Friday, July 14, 2017.(Photo: Rodney White/The Register)

"It's a challenge, and one I don't think some private dentists are up to," Harvey said in explaining the administrative hurdles her staff faces in working with low-income clients.

The Iowa Ombudsman and the Long-Term Care Ombudsman both said last week they have not had complaints about the dental privatization.

Stanton resident Richard Zablotney, 73, said he has attempted to obtain dental services for months using the Medicaid dental programs, even before Iowa switched July 1 to private management.

He said he was first denied because of his age but that was reversed soon after he appealed.

Zablotney said he obtained new cards for the July 1 switch to private companies but continues to wrestle with details about what services are covered and what dentist will see him.

He said he has eaten only soft foods in recent weeks because of his ailing teeth.

“I’ve never taken an illegal drug or committed a crime in my life,” Zablotney said. “I’ve paid my taxes, and now a private company is determining what my health coverage will be, and my health is suffering right now.”